Fellowship Experience – Perth, Australia

Dr Lucy Childs is a UK radiology trainee who has been out in Perth, Australia doing her neuroradiology fellowship. She has very kindly shared her experiences and advice on the fellowship with us below:

NIISWA is the Neurological Imaging and Intervention Service of Western Australia.

There is a link here to information about the fellowship: http://niiswa.com/index.php/fellowships.html

There are 3 diagnostic fellows and 1 neuro intervention fellow each year. The fellowship is typically one year long, but can be extended to 2 years, particularly for the interventional fellows.

It’s a tertiary Neuroimaging specialist centre with advanced neuroimaging techniques including CT and MR perfusion, spectroscopy, functional MR imaging etc. NIISWA runs a 24 hour mechanical thrombectomy service for acute strokes, as well as the usual gamut of neurointervention (aneurysms/ AVM management/ stents etc.)

As a fellow you work across two hospital sites: Sir Charles Gairdner Hospital (SCGH) and the Royal Perth Hospital (RPH). These are both public hospitals (like NHS). SCGH is the regional neuro-oncology centre with a large neurosurgical department. The state trauma unit is sited at RPH.

There are two MRI scanners at SCGH one 1.5 and one 3T, (same at RPH). The MRI scanners work almost exclusively performing neuroimaging. The MRI and CT radiographers are excellent, very experienced and tailor scans to the specific clinical requirements, working closely with the neuroradiology team. The MRI scanners work from 0800-1700 for inpatient scanning and 0615-2200 for outpatient scanning with additional out-of-hours oncall service.

The job is busy, there is a large exposure to pathology with a high volume of abnormal scans. Very few ‘normal’ scans are performed by NIISWA. At SCGH CT imaging is reported by general radiologists with referral to NIISWA only when specialist input is required. At this site imaging is predominantly MRI based. All modalities are reported by NIISWA at RPH.

As a diagnostic fellow you are expected to perform fluoroscopically guided lumbar punctures, fluoroscopic and CT guided facet joint injections, fluoroscopically-guided nerve root sleeve injections, fluoroscopically-guided epidural injections and spinal markings prior to surgery. If you are not interested in or not comfortable with performing procedures most days of the week (usually at least 1-2/day) then this fellowship might not be the one for you, as this is entirely expected.

There is the opportunity to do head and neck reporting. H&N reporting is nearly all cross-sectional, with almost no ultrasound imaging as this is performed by sonographers at NIISWA, although you are still part of the FNA service.

As a fellow you actively participate in journal club meetings, CME lectures and MDT presentations. Teaching is generally case based and there is excellent senior consultant supervision at all times.

The pay is excellent. Typically equates to £125,000/ year ($200,000 AUD) when on call payments are included (these are variable). The on call is 1 week in every 4 and you are essentially on call from home 5pm-8am and working your normal hours the rest of the week. Annual leave is unfortunately very low in your first year at only 20 days/year. There are no zero days before or after on calls either.

Western Australia is an enormous geographical area with its own unique challenges. It’s not uncommon for ‘flying doctors’ to bring patients from many hundreds of kilometres away from small remote Australian communities. In combination with socio-economic problems, this leads to cases more often seen in developing countries – indeed it is the only place where I have encountered cases of leprosy.

Overall, this is a very educational fellowship with an excellent supportive neuroimaging team. The downsides would include the lack of time off (to explore the area). Perth also feels like a very ‘new’ city which is currently short on culture and multiculturalism, but is making progressive attempts to improve this. There are also incredible beaches which do go some way in offsetting the lack of art establishments!

Our thanks to Lucy for sharing such detailed information about the fellowship – if you are currently undertaking a neuroradiology fellowship in the UK or abroad, please do get in touch and tell us what you think about it!

August Journal Round-Up

It’s that time of the month again – welcome to the August journal round-up!

Emergency – The longstanding issue of blunt cerebrovascular injury following craniocervical injury was again on the agenda this month; Cook et al. came to the conclusion that for these purposes children may well be little adults, as the modified Denver criteria have a high sensitivity for these injuries. However, the issues of radiation dose and what treatment is appropriate have not yet been settled. To further complicate matters, Grandhi et al. in JNS found that CTA has a high false positive rate for BCVI (in adults), particularly for Biffl grade 1 injuries, and suggest that these should be confirmed with DSA which brings its own problems.

Away from these thorny issues, Rozell et al. present a case based approach to infectious and inflammatory conditions presenting to the emergency department in Emergency Radiology, which may be a particularly useful summary to registrars starting their neuro blocks.

Vascular/Intervention – Optimising endovascular therapy for stroke and the pre-procedural imaging remains a dominant theme of this month’s journal articles. A retrospective analysis of MR CLEAN trial data published in Radiology by Jansen et al. demonstrated that the opacification of cerebral veins (using a scoring system based on three areas) predicted the response to intra-arterial therapy, although this relied on satisfactory venous opacification on a CTA. Sallustio et al. in AJNR showed that using the ASPECTS score on CTA was a better predictor of outcome than using it on non-contrast CT, although also in AJNR Pfaff et al. demonstrated the utility of automated ASPECTS scoring (e-ASPECTS) as this also correlated with outcome (as well as with expert raters).

Tumour – The spectrum of leptomeningeal malignancy and its mimics is covered in a handy pictorial review in Neurographics by Salehi et al., including the multitude of leptomeningeal neoplasms as well as infectious and inflammatory causes. Mimics are also the subject of an article by Starr and Cha in Clinical Radiology, which highlights five key features to alert the radiologist that an apparent meningioma may not be what it seems – significantly high or low T2 hyperintensity, osseous destruction, leptomeningeal extension and lack of a dural tail. Finally, in JNS Starke et al. examine the dreaded pineal cyst, examining key features from their cohort that are associated with hydrocephalus and malignant transformation.

DegenerativeJennings et al. in JAMA Neurology showed the predictive value of dopaminergic imaging in Parkinson’s disease, showing that a combination of hyposmia and positive DAT-SPECT predicts a conversion to PD within four years; this could also be used as a quantitative biomarker to measure disease progression over time. It is worth also checking out the accompanying editorial (by Postuma) which places the findings in context.

Cerebral amyloid angiopathy is a common diagnosis but still presents a diagnostic dilemma and our pathophysiological understanding of the condition remains incomplete. Two articles published this month aim to help tackle this and are complementary in their aims. Firstly, a comprehensive radiological review in Neurographics, by Koren et al., which covers the imaging features and Boston diagnostic criteria as well as the rarer inflammatory subtype. Secondly, a broader, more clinically orientated overview in JNNP by Banerjee et al. examines the current state of knowledge and future directions for diagnosis and treatment.

SpineKralik et al. studied the utility of 3D SPACE imaging for the diagnosis of spinal dural arteriovenous fistula; as expected, abnormal flow voids associated with dAVFs were better seen on 3D imaging, however the authors stress the importance of using this in tandem with 2D T2 imaging for assessing cord signal change.

Miscellaneous – I never know which section PRES belongs in, and it seems I’m in good company as a practical review of the condition outlines in JNNP this month. Gao et al. present a review of the different theories of aetiology for this heterogeneous disorder, and most importantly for the radiologist stress that the diagnosis of PRES is far from the endpoint of investigation and should prompt a search for underlying causes.

With the controversy surrounding the significance of gadolinium deposition in the brain still very much alive, a review of pathology of the dentate nucleus seems timely, and Bond et al. provide a thorough summary of the functional anatomy and conditions affecting this area.

And finally, public service announcement of the month goes to Sriram et al. in JNS, who presented a case of penetrating spinal injury by a swordfish – a key differential to consider in the fisherman presenting with hemiparesis.

That’s all for this month, do let us know what you’ve found useful this month! Coming up over the next couple of weeks we have a summary of the recent UKNG annual meeting, and we’ll have highlights from the BSNR Annual Meeting towards the end of September – do follow us on @BSNRTrainees for updates.

 

BSHNI Annual Meeting – Highlights

The excellent annual BSHNI meeting was held in London at the Royal Society of Medicine last month. Here, BSHNI trainee representative Phil Touska picks his highlights from the meeting:

Highlights from the July 2017 BSHNI meeting:

  • Trauma session
    • Following the tragic events in Manchester and London this year, the first session focused upon the crucial role of radiology in managing such patients.
    • Important messages included:
      • Ensuring all radiology departments plan for emergencies, ensuring that protocols are in place in the case of multiple unexpected simultaneous casualties.
      • With regard to penetrating neck injury, defining the ‘zones’ is less important than defining the structures and viscera transgressed.
      • Facial buttresses are key to assessing and reporting facial skeletal trauma and injuries to the lacrimal fossa may affect important ocular attachments.
      • Radiologists need to be prepared for blast injuries they may be unfamiliar with (see Hare et al. 2007).
    • High Field MR
      • Dr Verbist & Prof Webb presented some of their inspirational work using 7T MR, highlighting some of the advantages, particularly with regard to local staging of head and neck tumours, but technical challenges, such as less predictable tissue heating patterns secondary to the altered electromagnetic field interfaces also arise at high field strength.
    • Robots in the head & neck
      • Transoral robotic surgery (TORS) for oropharyngeal carcinoma is becoming available in several centres across the country – radiology can not only provide staging information for surgical planning, but also highlight surgical risks such as medialised carotid arteries. Loevner et al. provide a useful review of TORS for the head and neck radiologist.
    • Thyroid ablation
      • Drs Morley and Otero highlighted their experiences with radiofrequency ablation of benign thyroid nodules following the recent NICE guidance – early results seem promising (Lim et al. 2013) and it may be a viable alternative to surgery in some cases, but the team highlighted the potential risks (Baek et al. 2012) and the importance of relevant technical skills and facilities.

July Journal Round-Up – Head & Neck

Phil Touska is the new trainee representative for the British Society of Head and Neck Imaging (BSHNI), and here’s his thoughts on the most recent and relevant publications in head and neck radiology:

Head & Neck Cancer

AJCC 8 is on its way and promises to improve the accuracy of staging and correlation with survival and reflects more recent data. The main changes include separate staging for HPV related and non-HPV related SCC, reflecting the more favourable prognosis of HPV related disease. In addition, depth of invasion is now included in the staging of oral cancer (small, but deeply invasive lesions carry a worse prognosis) and there is a new N3b stage for non-HPV related SCC, reflecting extranodal spread (Lydiatt et al. Jan 2017).

Otology

Whilst the ‘third eye’ might provide insight, the ‘third window’ is associated with a diminution of the senses, hearing loss in particular. Although many of us may have come across semicircuar canal dehiscence, the aetiology of the associated hearing loss and the spectrum of similar conditions may be less familiar. Ho et al. provide an excellent insight into the various different abnormalities that may cause ‘third window’ defects (Ho et al.  2017).

Rhinology

A group of rhinologists have recently convened to discuss the scintillating topic of the frontal sinus and its drainage pathway. This resource is helpful if you are communicating with surgeons carrying out endoscopic procedures in this region, alerting them to supra-agger or supra bulla cells (Wormald et al. 2016). A further helpful resource on frontal sinus drainage pathway anatomy can be found in the AJNR (Daniels et al. 2003).

Trauma

Reviewing soft tissue radiographs of the neck for foreign bodies can occasionally result in confusion and pitfalls abound. If you have ever wondered about the location of the triticeous cartilage or wanted to know the ossification patterns of the cricoid and aretyoid cartilages, look no further than Radiographics (Castan Senar et al. 2017), free for RSNA members.

Techniques

There is increasing interest in the use of dual energy CT in the head and neck. It works on the principle of imaging at two tube voltages, the photoelectric effect predominating at the lower voltage; hence, enhancing lesions will attenuate more, increasing conspicuity. The technique can also be used to isolate iodine creating ‘iodine maps’ to delineate lesions, create virtual non-contrast studies and reduce deleterious metal artefact Roele et al. 2017 and Vogl et al. 2012.

Phil can be contacted on bshnitrainees@gmail.com. Look out for his summary of the 2017 British Society for Head and Neck Imaging Annual Meeting coming later this week!

 

  • Lydiatt WM, Patel SG, O’Sullivan B, Brandwein MS, Ridge JA, Migliacci JC, Loomis AM, Shah JP. Head and Neck cancers-major changes in the American Joint Committee on cancer eighth edition cancer staging manual. CA Cancer J Clin. 2017 Mar;67(2):122-137.
  • Ho ML, Moonis G, Halpin CF, Curtin HD. Spectrum of Third Window Abnormalities: Semicircular Canal Dehiscence and Beyond. AJNR Am J Neuroradiol. 2017 Jan;38(1):2-9.
  • Castán Senar A, Dinu LE, Artigas JM, Larrosa R, Navarro Y, Angulo E. Foreign Bodies on Lateral Neck Radiographs in Adults: Imaging Findings and Common Pitfalls. Radiographics. 2017 Jan-Feb;37(1):323-345.
  • Wormald PJ, Hoseman W, Callejas C, Weber RK, Kennedy DW, Citardi MJ, Senior BA, Smith TL, Hwang PH, Orlandi RR, Kaschke O, Siow JK, Szczygielski K, Goessler U, Khan M, Bernal-Sprekelsen M, Kuehnel T, Psaltis A. The International Frontal Sinus Anatomy Classification (IFAC) and Classification of the Extent of Endoscopic Frontal Sinus Surgery (EFSS). Int Forum Allergy Rhinol. 2016 Jul;6(7):677-96.
  • Daniels DL, Mafee MF, Smith MM, Smith TL, Naidich TP, Brown WD, Bolger WE, Mark LP, Ulmer JL, Hacein-Bey L, Strottmann JM. The frontal sinus drainage pathway and related structures. AJNR Am J Neuroradiol. 2003 Sep;24(8):1618-27.
  • Roele ED, Timmer VCML, Vaassen LAA, van Kroonenburgh AMJL, Postma AA. Dual-Energy CT in Head and Neck Imaging. Curr Radiol Rep. 2017;5(5):19.
  • Vogl TJ, Schulz B, Bauer RW, Stöver T, Sader R, Tawfik AM. Dual-energy CT applications in head and neck imaging. AJR Am J Roentgenol. 2012 Nov;199(5 Suppl):S34-9.

July Journal Round-Up

Welcome to the July journal round-up! This month we are privileged to welcome the British Society of Head and Neck Imaging’s trainee representative, Phil Touska, who has kindly written a companion round-up for head and neck radiology. Also look out for his summary of the recent BSHNI Annual Meeting on this blog next week. But to start with, this month’s neuro…

Emergency – Two review articles published this month on very different topics both illustrate the vital importance of understanding the clinical context when interpreting imaging. Siddiqui et al. in Emergency Radiology tackle the tricky area of the craniocervical junction and associated traumatic injuries, with reference to appropriate neurosurgical management. Similarly, in AJR Reiter et al. cover normal postoperative appearances following traumatic midface fractures and associated complications, focusing on understanding the operative techniques used to maximize utility to the maxillofacial surgeons.

Vascular/Intervention Caldwell et al. in Practical Neurology have written a concise and practical summary of acute stroke imaging covering important pitfalls in interpretation and appropriate imaging pathways. Within the setting of stroke, a number of articles this month focus on areas requiring further research following the major mechanical thrombectomy trials – for example, Satti et al. performed a retrospective review of mechanical thrombectomy in a paediatric population; although good recanalization rates and clinical outcomes were demonstrated, only 29 patients were included so further work is required. Hoving et al. looked at intracranial occlusions secondary to internal carotid artery dissections, and a systematic review also demonstrated largely favourable outcomes from endovascular treatment, but noted that the studies included were mainly case reports/series so again only limited conclusions could be drawn.

Away from vascular intervention, the trials and tribulations of image-guided lumbar puncture have been on the agenda, with a pragmatic problem-solving approach in AJNR to difficult adult LPs and a guide to ultrasound-guided paediatric LPs in Pediatric Radiology.

Tumour – In JNNP this month, Voets et al. review the white matter tracts pertinent to neuro-oncology treatment, covering functional and anatomical aspects and providing a thorough overview of the relevant tracts which will act as a useful reference guide. Another area of increasing importance in neuro-oncology is radiogenomics and the molecular-radiologic correlations following the updated WHO classification, and Smits and van den Bent have provided a detailed analysis of the known imaging features of glioma subtypes in Radiology – this will become increasingly important in neuro-oncology MDTs.

Inflammatory – With the uncertainty about gadolinium deposition continuing to feature heavily in the literature, Gupta et al. have looked into other ways of imaging disease activity in multiple sclerosis without the use of contrast, performing a meta-analysis and demonstrating some promise for DTI (fractional anisotropy).

Degenerative – A large scale study from Iceland published in JAMA Neurology examined the relevance of large perivascular spaces, and found that they are associated with a significantly increased risk of vascular dementia and are a marker for small vessel disease – and thus should be reported in cognitive impairment studies in the older population. In JNNP, Gellersen et al. examined cerebellar atrophy and found in a systematic review that patterns of atrophy were useful in discriminating neurodegenerative diseases. It is also a helpful reminder of the functional anatomy and connectivity of the cerebellum.

Paediatric – Hypoxic ischaemic encephalopathy in neonates can be difficult to diagnose and prognosticate from on MRI. A study by Trivedi et al. in Pediatric Radiology validates an MRI scoring system that can be used clinically, and was shown to predict neurodevelopmental outcomes at 18-24 months. Although multiple scoring systems exist, the authors contend that this is the first to incorporate DWI and this provides at the very least a practical checklist for abnormalities to assess for in the setting of HIE.

Hacohen et al. have developed a diagnostic algorithm for CNS demyelination in children, summarising discriminating radiological and laboratory test features between different demyelinating diseases, and highlighting imaging features of MOG-related disease.

Spine – In AJR, Anderson et al. have reviewed the imaging findings in chronic adhesive arachnoiditis, providing a helpful guide to this heterogeneous but debilitating disorder.

Particularly important for centres that perform aortic intervention, Gialdini et al. have investigated the occurrence of spinal cord infarction following aortic dissection and aneurysm repair. They found an incidence of 1/130 in dissection or ruptured aneurysm repair and 1/600 in unruptured aortic repair, which is important both for the vigilance of the neuroradiologist in this setting and communication of risk by the interventionalist.

Other – Contrast agents remain hot topics and whilst we worry about gadolinium deposition, there is good news from the CT side with a systematic review and meta-analysis by Brinjikji et al. which provides nonrandomized evidence that contrast given in the setting of acute stroke (CTA/CT perfusion) is not associated with acute kidney injury even in patients with chronic kidney disease.

And finally, for all those exhausted by multiple pineal cyst referrals to MDTs, you may wish to distribute Ramji et al.’s valuable pictorial review on normal neuroanatomical variants that can be misinterpreted to your referrers (after a careful peruse yourself!).

That’s all for neuro this month, but please click here to go on to Phil’s excellent roundup for head and neck imaging…

 

  1. Siddiqui J, Grover PJ, Makalanda HL, Campion T, Bull J, Adams A. The spectrum of traumatic injuries at the craniocervical junction: a review of imaging findings and management. Emerg Radiol. 2017 Aug 1;24(4):377–85.
  2. Reiter MJ, Schwope RB, Theler JM. Postoperative CT of the Midfacial Skeleton After Trauma: Review of Normal Appearances and Common Complications. American Journal of Roentgenology. 2017 Jul 13;W1–11.
  3. Caldwell J, Heran MKS, McGuinness B, Barber PA. Imaging in acute ischaemic stroke: pearls and pitfalls. Practical Neurology. 2017 Jul 25;practneurol-2016-001569.
  4. Satti S, Chen J, Sivapatham T, Jayaraman M, Orbach D. Mechanical thrombectomy for pediatric acute ischemic stroke: review of the literature. Journal of NeuroInterventional Surgery. 2017 Aug 1;9(8):732–7.
  5. Hoving JW, Marquering HA, Majoie CBLM. Endovascular treatment in patients with carotid artery dissection and intracranial occlusion: a systematic review. Neuroradiology. 2017 Jul 1;59(7):641–7.
  6. Hudgins PA, Fountain AJ, Chapman PR, Shah LM. Difficult Lumbar Puncture: Pitfalls and Tips from the Trenches. American Journal of Neuroradiology. 2017 Jul 1;38(7):1276–83.
  7. Muthusami P, Robinson AJ, Shroff MM. Ultrasound guidance for difficult lumbar puncture in children: pearls and pitfalls. Pediatr Radiol. 2017 Jun 1;47(7):822–30.
  8. Voets NL, Bartsch A, Plaha P. Brain white matter fibre tracts: a review of functional neuro-oncological relevance. J Neurol Neurosurg Psychiatry. 2017 Jul 14;jnnp-2017-316170.
  9. Smits M, van den Bent MJ. Imaging Correlates of Adult Glioma Genotypes. Radiology. 2017 Jul 19;284(2):316–31.
  10. Gupta A, Al-Dasuqi K, Xia F, Askin G, Zhao Y, Delgado D, et al. The Use of Noncontrast Quantitative MRI to Detect Gadolinium-Enhancing Multiple Sclerosis Brain Lesions: A Systematic Review and Meta-Analysis. American Journal of Neuroradiology. 2017 Jul 1;38(7):1317–22.
  11. Ding J, Sigurðsson S, Jónsson PV, Eiriksdottir G, Charidimou A, Lopez OL, et al. Large Perivascular Spaces Visible on Magnetic Resonance Imaging, Cerebral Small Vessel Disease Progression, and Risk of Dementia: The Age, Gene/Environment Susceptibility–Reykjavik Study. JAMA Neurol [Internet]. 2017 Jul 17 [cited 2017 Jul 27]; Available from: http://jamanetwork.com/journals/jamaneurology/fullarticle/2643984
  12. Gellersen HM, Guo CC, O’Callaghan C, Tan RH, Sami S, Hornberger M. Cerebellar atrophy in neurodegeneration—a meta-analysis. J Neurol Neurosurg Psychiatry. 2017 May 27;jnnp-2017-315607.
  13. Trivedi SB, Vesoulis ZA, Rao R, Liao SM, Shimony JS, McKinstry RC, et al. A validated clinical MRI injury scoring system in neonatal hypoxic-ischemic encephalopathy. Pediatr Radiol. 2017 Jun 16;1–9.
  14. Hacohen Y, Mankad K, Chong WK, Barkhof F, Vincent A, Lim M, et al. Diagnostic algorithm for relapsing acquired demyelinating syndromes in children. Neurology. 2017 Jul 18;89(3):269–78.
  15. Anderson TL, Morris JM, Wald JT, Kotsenas AL. Imaging Appearance of Advanced Chronic Adhesive Arachnoiditis: A Retrospective Review. American Journal of Roentgenology. 2017 Jun 22;1–8.
  16. Gialdini G, Parikh NS, Chatterjee A, Lerario MP, Kamel H, Schneider DB, et al. Rates of Spinal Cord Infarction After Repair of Aortic Aneurysm or Dissection. Stroke. 2017 Jan 1;STROKEAHA.117.017071.
  17. Brinjikji W, Demchuk AM, Murad MH, Rabinstein AA, McDonald RJ, McDonald JS, et al. Neurons Over Nephrons. Stroke. 2017 Jul 1;48(7):1862–8.
  18. Ramji S, Touska P, Rich P, MacKinnon AD. Normal neuroanatomical variants that may be misinterpreted as disease entities. Clinical Radiology [Internet]. 2017 Jul 23 [cited 2017 Jul 27];0(0). Available from: http://www.clinicalradiologyonline.net/article/S0009-9260(17)30348-3/fulltext

 

June Journal Round-Up

Welcome to the June neuroradiology journal round-up! Below are some of the most useful articles (in my humble opinion) for neuroradiology trainees from this month, separated into categories – do let me know of any you think should be on here!

Emergency – When it comes to emergency neuroimaging this month, the eyes have it; both Emergency Radiology and Radiographics have articles focusing on this potential ‘blind spot’ for radiologists. Thelen et al. present a concise pictorial review of post-traumatic injuries, while Nguyen et al. cover a more all-encompassing range of orbital pathologies including infection, trauma, vascular disease and inflammation. Taken together, they are a useful reminder and reference for an important review area on the emergency CT head.

Also in Emergency Radiology, a sadly ever more relevant overview of penetrating brain trauma by Vakil and Singh focuses on bullet injuries. A particularly interesting section focuses on the wound types caused by different motion of the bullet at time of impact, with implications for ongoing management and prognosis, and there is an equally important discussion of complications following these injuries.

Vascular – Intracranial vascular malformations have been a hot topic this month, with an overview of cerebral arteriovenous malformation imaging in AJR timed perfectly to coincide with a consensus statement on their management in Stroke, which provides important clinical context for neuroradiologists as well as more direct management guidance for interventionalists.

Also in Stroke, there is a comprehensive topical review of dural arteriovenous malformations by Reynolds et al., and the supplemental material contains detailed information on treatment options and outcomes.

Away from vascular malformations, an editorial in Neurology by Carrera and Wintermark examines the issue of imaging-based selection for acute stroke treatment, and essentially the utility of perfusion CT in this context, which will presumably become more and more relevant in the era of mechanical thrombectomy.

Intervention – Interventionalists will be interested to read the concise multi-organisation working group consensus guidelines for ‘Standards of Practice in Interventional Neuroradiology’ published in Neuroradiology this month. Perhaps with some relevance to these standards, in JNNP early results from a trial of clipping versus coiling of unruptured aneurysms demonstrated no difference in morbidity at one year, but an increase in neurological deficits and hospitalisation of over five days in the clipping group.

Inflammatory/Infection – The gamut of imaging findings in viral infections of the CNS can be bewildering, and a virus-by-virus breakdown in Emergency Radiology serves as a handy reference guide. Similarly, there is an expanding subset of autoimmune encephalitides, and an open access AJNR review by Kelley et al. dives into the distinguishing features and clinical importance of the different subtypes – particularly striking is the apparent prevalence of NMDA receptor encephalitis in young patients with limbic encephalitis (apparently more than any single viral aetiology in young patients, according to the California Encephalitis Project). Elsewhere, a pragmatic and worthwhile update on multiple sclerosis imaging in the BJR by Igra et al. focuses on diagnostic criteria and treatment related complications.

Degenerative – As the article by Harper et al. in JNNP points out, imaging studies in dementia rarely have pathological confirmation of dementia type, so this study of 215 pathologically confirmed people with dementia is a very valuable resource for delineating patterns of atrophy and will hopefully have practical clinical applications.

PaediatricHaverkamp et al. provide an overview and pictorial essay of paediatric spinal neoplasms in this month’s Neurographics, with useful summary differential diagnosis tables for lesions in each spinal compartment, and there is a focus on surrounding further investigations and management for each pathology.

Spine – In JNS Spine this month, Schultz et al. offer some tips for the clinicoradiological conundrum of differentiating dorsal arachnoid webs from anterior spinal cord herniation, performing a cohort study of a small number of patients with each. The most useful signs to differentiate the two were the shape of the dorsal indentation (‘scalpel-shaped’ in DAW, ‘C-shaped’ in SCH) and the presence of a preserved ventral CSF plane in DAW.

Other – Synthetic MRI is an exciting prospect, potentially allowing multiple sequences to be reconstructed from a single scan and thereby significantly reducing scan times, but its potential has not yet been fully assessed. The MAGiC prospective trial, published in AJNR, takes a significant leap in that direction, demonstrating noninferiority of multiple sequences, although currently with increased artefacts affecting T2 FLAIR. Watch this K-space!

With growing interest in the long-term effects of repeated Gadolinium agent administration, ISMRM has published a summary of the evidence along with their recommendations for clinical and research use in the Lancet Neurology – the driving point of which is that we know that gadolinium is deposited, but we do not know what the biological significance of this is as yet and further research is required.

Finally, a great excuse for medical students at the back of lecture halls everywhere – students who spent longer playing on a smartphone game performed better on a simulated interventional radiology task (renal artery cannulation) in an article in Clinical Radiology, and only in those who played for more than 5 hours a week. So that’s what all those interventionalists sitting in meetings are doing…

That’s all for now. Let me know if you find these articles helpful, and about anything else you’ve been reading this month!

 

References

1. Thelen J, Bhatt AA, Bhatt AA. Emergency orbital pathology: what the radiologist should know. Emerg Radiol. 2017 Jun 17;1–8.
2. Nguyen VD, Singh AK, Altmeyer WB, Tantiwongkosi B. Demystifying Orbital Emergencies: A Pictorial Review. RadioGraphics. 2017 Apr 21;37(3):947–62.
3. Vakil MT, Singh AK. A review of penetrating brain trauma: epidemiology, pathophysiology, imaging assessment, complications, and treatment. Emerg Radiol. 2017 Jun 1;24(3):301–9.
4. Tranvinh E, Heit JJ, Hacein-Bey L, Provenzale J, Wintermark M. Contemporary Imaging of Cerebral Arteriovenous Malformations. American Journal of Roentgenology. 2017 Mar 7;208(6):1320–30.
5. Derdeyn CP, Zipfel GJ, Albuquerque FC, Cooke DL, Feldmann E, Sheehan JP, et al. Management of Brain Arteriovenous Malformations: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2017 Jan 1;STR.0000000000000134.
6. Reynolds MR, Lanzino G, Zipfel GJ. Intracranial Dural Arteriovenous Fistulae. Stroke. 2017 May 1;48(5):1424–31.
7. Carrera E, Wintermark M. Imaging-based selection of patients for acute stroke treatment Is it ready for prime time? Neurology. 2017 Jun 13;88(24):2242–3.
8. Jansen O, Szikora I, Causin F, Brückmann H, Lobotesis K. Standards of practice in interventional neuroradiology. Neuroradiology. 2017 Jun 1;59(6):541–4.
9. Darsaut TE, Findlay JM, Magro E, Kotowski M, Roy D, Weill A, et al. Surgical clipping or endovascular coiling for unruptured intracranial aneurysms: a pragmatic randomised trial. J Neurol Neurosurg Psychiatry. 2017 Jun 20;jnnp-2016-315433.
10. Maller VV, Bathla G, Moritani T, Helton KJ. Imaging in viral infections of the central nervous system: can images speak for an acutely ill brain? Emerg Radiol. 2017 Jun 1;24(3):287–300.
11. Kelley BP, Patel SC, Marin HL, Corrigan JJ, Mitsias PD, Griffith B. Autoimmune Encephalitis: Pathophysiology and Imaging Review of an Overlooked Diagnosis. American Journal of Neuroradiology. 2017 Jun 1;38(6):1070–8.
12. Igra MS, Paling D, Wattjes MP, Connolly DJA, Hoggard N. Multiple sclerosis update: use of MRI for early diagnosis, disease monitoring and assessment of treatment related complications. BJR. 2017 Apr 26;90(1074):20160721.
13. Harper L, Bouwman F, Burton EJ, Barkhof F, Scheltens P, O’Brien JT, et al. Patterns of atrophy in pathologically confirmed dementias: a voxelwise analysis. J Neurol Neurosurg Psychiatry. 2017 May 4;jnnp-2016-314978.
14. Haverkamp BT, Nizamuddin RA, Loskutov A, Lowe LH, Adler KE. Imaging Spectrum of Pediatric Spinal Neoplasms [Internet]. 2017 [cited 2017 Jun 25]. Available from: http://asnr.publisher.ingentaconnect.com/content/asnr/ng/2017/00000007/00000003/art00001
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Welcome

The aim of this blog is to provide a resource for neuroradiology trainees (and any other interested readers), and collect useful information from other sources in one helpful package. To this end, I will post a monthly round-up of articles which I think are of interest to neuroradiology trainees, and hopefully in future expand to cover other useful resources, potentially including (but not restricted to!):

  • Course and conference reviews/updates
  • Blogs on research/publications undertaken by neuroradiology trainees by the researchers themselves
  • Advice on fellowship/consultant posts and applications

This will only be useful with your collaboration, so please do get in touch if you would like to contribute any of the above, or have any other ideas you would like to explore. I would also be interested to know which articles/resources you find useful in training, particularly any I miss in the monthly round-up, as I would like to build up a repository of useful articles to eventually complement the new curriculum.

Do get in touch via the comments below or on bsnrtrainee@gmail.com.

Tom (BSNR Trainee Rep)